Ablative Reversal of Barrett Esophagus to Reduce Cancer Risk

Summary and Comment |
November 17, 2006

Ablative Reversal of Barrett Esophagus to Reduce Cancer Risk

  1. David A. Johnson MD

Questions remain to be answered before ablative therapy is put into practice.

  1. David A. Johnson MD

The goal of therapy for Barrett esophagus (BE) patients is to control acid reflux and heal any related mucosal damage. The hope is that such efforts will decrease the long-term risks for dysplasia and neoplastic progression. Elimination of the BE epithelium has been proposed to lower or eliminate long-term cancer risk. Successful reduction or elimination of BE, via a number of ablative therapies, has been reported, but little comparative or long-term data exist to adequately assess the effectiveness of such interventions.

Investigators in Arizona and Missouri enrolled 35 patients in a BE endoscopic surveillance program. At baseline, all patients received rabeprazole (20 mg twice daily) and underwent 24-hour pH testing; 26 (74.3%) had normalized intraesophageal acid exposure. Patients were stratified by BE length (2–6 cm) and randomized to undergo mucosal ablation with either multipolar electrocoagulation (MPEC) or argon-plasma coagulation (APC). Treatments were performed every 4 to 8 weeks until no endoscopic evidence of BE remained or for a maximum of 6 sessions; patients were followed for at least 2 years. The mean number of sessions required to achieve complete reversal was similar for both methods (MPEC, 4.3 sessions; APC, 3.6). Complete endoscopic and histologic reversal of BE was evident in 82.8% of patients on the first surveillance endoscopy after ablation. Long-term follow-up endoscopy showed maintenance of complete BE reversal in 68.5%. Once ablation was complete, rabeprazole was reduced to 20 mg daily or to whatever dose was necessary to control symptoms. No factor (e.g., BE length, 24-hr pH scores, hiatal hernia size, age, number of treatments, or maintenance proton-pump–inhibitor [PPI] dose) predicted long-term reversal of BE with either ablative method.

Comment

Although both techniques showed reasonable long-term efficacy at 2 years, questions remain. Specifically, how durable is the treatment beyond 2 years? What are the risk factors for progression? What level of acid suppression is optimal for treatment and maintenance of neosquamous epithelium? Interestingly, 26% of these patients continued to exhibit pathologic esophageal acid exposure despite high-dose treatment with PPIs. In my opinion, ablative interventions for BE should not be offered in clinical practice until these answers are provided by scientific studies.

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